Sunnycrest Senior Living

Report specified resident events within seven days

87211(a)(1) Reporting Requirements (a) Each licensee shall … (1) A written report ... to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) .. of the case. This requirement was not met as evidenced by: Based on interviews and record review, the facility first became aware of the pressure injuries on August 11, 2025, the POA was not aware until August 18, 2025, prior to requesting R1 be sent to the hospital, which posed a potential safety risk to persons in care.

Call 9-1-1 for imminent health threats

87465(g) Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, ... medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).This requirement was not met as evidenced by: Based on interviews and record review, R1 was observed with pressure injuries one week before hospitalization and the facility did not seek immediate medical attention, which posed an immediate Health, Safety, and Personal Rights risk to persons in care. The facility only arranged for R1’s hospitalization for assessment after his POA requested it.

Care and supervision as defined by statute and rules

87464(f)(1) Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).This requirement was not met as evidenced by: Based on interviews and record review, licensee did not find a solution necessary to prevent and address R1’s pressure injuries, R1 continued being placed in his wheelchair, and was not being repositioned in it, which posed an immediate Health, Safety, and Personal Rights risk to persons in care. Due to lack of care and supervision, R1 sustained stage 3 and unstageable pressure injuries.

9877 General Food Service Requirements (b) The following food service requirements shall apply: (18) Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents.This requirement was not met as evidenced by: Based on interviews, ED confirmed the delay in food service due to staff turnover also corroborated by four out of eight residents/staff which poses a potential Health, Safety, and/or Personal Rights risk to persons in care.

87464 Basic Services (f) Basic services shall at a minimum include: (2) Safe and healthful living accommodations and services...This requirement was not met as evidenced by: Based on interviews, six of eight residents and three of eight staff confirmed the delay in diapers changes which poses a potential Health, Safety, and/or Personal Rights risk to persons in care.

Facility must safeguard entrusted cash and valuables

87217 Safeguards for Resident Cash, Personal Property, and Valuables: (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property....This was not evidenced by: Based on interviews conducted, the Licensee did not ensure that R1's diapers were appropirately safeguarded. This poses a potential health, safety, and personal rights risk to persons in care.

Give PRN medication by physician order

87465 Incidental Medical and Dental Care(c) If the resident's physician has stated in writing that the resident ... provided all ... requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on observation, interviews, and record review, the facility did not administer medication to R1 as prescribed, which poses a potential Health, Safety, and Personal Rights risk to persons in care. Interviews conducted corroborated that R1 was administered R2's medication on 11/3/2025.

Report specified resident events within seven days

87211 Reporting Requirements (a) Eachlicensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events...This requirement was not met as evidenced by: Based on LPA's observation, interviews, and record review, the facility did not report R1's medication error to R1's family and physician and did not submit an report to the Department within 7 days of the event, which poses a potential Personal, Health, and Personal Rights risk to persons in care.

Provide resident hot water for personal care

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for....shall be maintained to automatically regulate ..to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). Based on LPA observation, the licensee did not comply with the section cited above in 4 out of 5 resident bathrooms, which poses an immediate health and safety risk to residents in care. LPA observed Rm#126 measure at 98.2, Rm#136 at 98.6, Rm# 276 at 103.1 and 263 measure at 104.5 degrees F.

Mark taps at high-temperature threshold

Based on observation, hot water temperatures in three out of ten rooms measured between 125.4 F and 130.2 f., which poses an immediate health and safety risk to residents in care. LPAs observed these temperatures above regulation in rooms 263, 276 and 126.

Store centrally held medications in locked secure place

Based on oberservation and interview, the licensee did not comply with the section cited above in two out of ten residentmedications, which poses an immediate health and safety risk to persons in care. LPA observed one or more medication unlocked in residents room and one medication ointment cannot be located by staff. The resident has a Dementia diagnosis.

Comply with all admission agreement terms

The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not being met as evidenced by... LPA observed that the admission agreeement states basic cable television hook-up will be provided but channel 39 is not being provided, 5 out of the 51 channels have poor picture quality with static and channel 15 does not have sound for R1, this poses a potential personal rights risk to residents in care.

Give PRN medication by physician order

87465(c)(2) Incidental Medical and Dental Care- …Once ordered by the physician the medication is given according to the physician's directions… This requirement was not met as evidence by: Licensee failed to ensure R1 received prescribed Eliquis medication twice CONTINUED... CONT... daily resulting in at least one missed dosage on the dates 8/13/23 and 8/15/23. As a result, R1 suffered a stroke and was diagnosed with a cerebral blood clot requiring surgery. This poses an immediate health and safety risk to residents in care.

Store centrally held medications in locked secure place

87465(h)(2) Incidental Medical and Dental Care- Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. CONT BELOW... This requirement was not met as evidence by: Licensee failed to ensure medications were locked inaccessible to R1 resulting in R1 ingesting another resident’s medication. This poses an immediate health and safety risk to residents in care.

Hazardous areas restricted from residents

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted.This requirement was not met as evidenced by: Based on the observations and interview, the backyard patio ground is uneven/unstable and may potentially be a safety risk to R1, who has a motor impairment. This poses a potential Health, Safety, or Personal Rights risk to the person in care.

Maintain facility in clean, safe, sanitary condition

Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services...for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: based on record review and interview the licensee did not ensure the side gate was properly secured at all times. This poses a potential risk to the health and safety of residents in care.

Administrator Qualifications and Duties. The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...shall apply. Good character and a continuing reputation of personal integrity. This requirement is not met as evidenced by: based on interview and record review the Licensee did not ensure ADMIN was of good character as they were under the influence of alcohol while working. This poses a potential risk to the health & safety of residents in care.

General Food Service Requirements. The following food service requirements shall apply: Equipment or appropriate size and type shall be provided for the storage, preparation and service of food and for sanitizing utensils and tableware, and shall be well maintained. This requirement is not met as evidenced by: based on observation & interview the licensee did not maintain specific kitchen equipment in good repair. This poses a potential risk to the health and safety of residents in care.

Assist residents with self-administered medication

Incidental Medical and Dental Care-The licensee shall assist residents with self-administered medications as needed.This requirement was not met as evidenced by: On 9/24/22, R1 went home with family for 2 days and medications were sent with the resident. According to family the resident received a double dose of medication. LPA also noted through a records review that the MAR was not documented correctly. The MAR was initialed that staff gave R1 medication however R1 was not present.

Personal rights of residents in all facilities

Personal Rights of Residents-The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.This requirement was not met as evidenced by: On 9/24/22 S1 sprayed R1's room with ant spray and did not remove R1 from the room.This posed an immediate Health and Safety and Personal Rights risk to residents in care.

Safe, healthful, comfortable accommodations

Personal Rights-To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement was not met as evidenced by: On 9/24/22, R1's sheets were not immediately changed when it was discovered that R1 had ants in her bed. Staff sprayed Raid and did not immediately change the sheets.This poses an immediate health and safety risk.

Facility maintenance and healthful environment

Personal Accomodations and Services-The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.This requirement was not met as evidenced by: On 9/24/22 R1 had ants in her bed sheets, on the railing of her bed and on her floor.This posed an immediate health and safety and personal rights risk to residents in care.

Maintain facility in clean, safe, sanitary condition

Maintenance and Operation-(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not being met as evidenced by: Based on interviews and records, R1's apartment unit not cleaned on February 22, 2022. This poses a potential risk to the residents in care.

Facility personnel sufficiency and competence

Facility personnel shall at all time be sufficient in numbers, and competent to provide the services necessary to meet residents needs. This requirement is not being met as evidenced by: Based on record review and interviews, staff failed to demonstrate competency in which R1 sustained three skin tears due to improper care and transfer from staff on December 2021, January 29, 2022 and February 28, 2022. R1 was roughly handled by staff. Facility staff did not have sufficient caregivers for R1's transfers. R1 was often left in the wheelchair after coming back from the dining room as R1 requires a two person staff. This poses an immediate risk to the residents in care.

Care and supervision as defined by statute and rules

Basic Services shall at a minimum include:(1) care and supervision as defined in Section 87101(c)(3) and Health and Safety Code Section 1569.2(c). This regulation was not met as evidence by: Licensee did not ensure that adequate care and supervision was provided to R1 as evidenced by that R1 did not receive regular incontinent care and proper showers. Staff forgot to bring R1 to a breakfast meal. This poses a potential risk to the resident in care.

Maintain facility in clean, safe, sanitary condition

Maintenance and Operation-(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not being met as evidenced by: Based on record review, and interviews, R1's room was observed to be dirty and had two roaches. R1's closet door was off track and was difficult to open. Two blinds were missing on the sliding door blinds. This poses a potential health & safety risk to residents in care

Personal rights of residents in all facilities

Personal Right of Residents in all Facilities- To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not being met as evidenced by: Based on record review, and interviews, Witness 1 observed the front door to be unlocked at 10:17 PM on August 18, 2022. Staff stated that they did not know how to lock the front automatic sliding door. This poses an immediate health & safety risk to residents in care.

Maintenance and Operation. Facilities shall have signal systems which shall meet the following criteria:(1) All facilities licensed for 16 or more and all residential facilities having separate floor or buildings shall have a signal system which shall: (A)Operate from each resident's living unit. This requirement is not being met as evidenced by: Based by interviews file review and observation, Administrator and staff admitted that a new auditory call system was installed on November 8, 2021 was not working properly which caused delays for staff to respond to residents requesting assistance when they pushed the auditory call system. This poses an immediate health & safety risk to residents in care.

Facility personnel sufficiency and competence

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not being met as evidenced by: Based on observation, record review, and interviews, staff 1 failed to demonstrate competency in dispensing medications as S1 did not know the name of the resident, room number medications because she left the medication cart with laptop the dining room on August 23, 2022. Staff went to R1's room to dispense her medications. Staff 1 is a new employee and has worked for the facility about three weeks and is not familiar with all the residents. S1 did not follow the facility's medication training and procedure. This poses an immediate health & safety risk to residents in care.

Authorized physician-prescribed self-administered meds

Incidental Medical and Dental Care... Assistance with self-administered medications shall be limited to … medications usually prescribed for self-administration which have been authorized by the person's physician. This requirement was not met as evidenced by: Based on the file review, observations and interviews, the facility, Staff 1 admitted that she was about to give R1 another resident's medication(R2). S1 was about to give R1 on 7/29/22, Senna and Citalopram which is not her medications and not authorized or ordered by her physician. This poses an immediate health & safety risk to residents in care

Maintain separate complete record for each resident

Resident Records- The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not being met as evidenced by: Based on observation, record review, and interviews, R1's responsible party did not receive August invoice after multiple requests. This poses a potential health & safety risk to residents in care.

Maintain facility in clean, safe, sanitary condition

Maintenance & Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not being met as evidenced by: Based on observation, record review, and interviews, Three out of three staff members interviewed have observed roaches in the facility. S1 and S2 observed roaches in the kitchen area. S3 observed roaches in several apartment units. W1 observed a roach in the Bistro area of the facility. This poses an immediate health & safety risk to residents in care.

Residents in all facilities must have rights

Peronal Right of Residents in all Facilities- To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not being met as evidenced by: Based on observation, record review, and interviews,Melanie Washington, Executive Director admitted that the facility back entrance unlocked and was propped open on the evening of August 25, 2022. Witness 1 visited the facility on the evening of August 25, 2022 at 11:50 PM and the back entrance was unlocked and propped open by a rock. This poses an immediate health & safety risk to residents in care

Telephone service and directory listing requirements

Telephones- All facilities shall have telephone service on the premises. This requirement is not being met as evidenced by: Based on observation, record review, and interviews,Melanie Washington, Executive Director was interviewed and stated that the facility phones are cordless and a staff forgot to charge the telephones on August 25, 2022. Witness 1 tried calling the facility on the evening of August 25, 2022 and no staff answered. This poses an immediate health & safety risk to residents in care

Assist residents with self-administered medication

Incidental Medical and Dental Care-The licensee shall assist residents with self-administered medications as needed. This requirement is not being met as evidenced by: Based on observation, record review, and interviews, Licensee did not assist residents with self-administered medications for thirty-eight residents on June 19, 2022 for morning medications. A Medication Technician called out on June 19, 2022 and the facility did not have a staff to pass out medications. The Administrator reported that thirty-eight residents missed their morning medications. This poses an immediate health & safety risk to residents in care.

Facility personnel sufficiency and competence

Personnel Requirements-General- Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not being met as evidenced by: Based on observation, record review, and interviews, the licensee did ensure adequate staff to meet resident's needs.The Administrator stated that the facility do not have sufficient staff to meet the needs of the residents. This poses an immediate health and safety to residents in care.

Report specified resident events within seven days

Reporting Requirements- (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence.. Based on observation and file review the facility staff failed to report the incident within seven days of the fall when resident 1 sustained an unwitnessed fall on 11/9/2021 and 911 emergency personnel was contacted.This poses a potential threat to the health, safety and/or personal rights to the resident in care.